Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely incontinence care for three residents who were dependent on staff for activities of daily living (ADLs), specifically incontinence care. All three residents had care plans directing staff to provide incontinence care every two hours and as needed. On the morning in question, these residents were not provided incontinence care from the end of the night shift (around 5:00 A.M.) until late in the morning, resulting in each being found with saturated incontinence briefs. Certified Nursing Assistants (CNAs) assigned to these residents did not provide the required care during their shift, with one CNA leaving the facility for personal reasons without attending to these residents. Another CNA subsequently provided care, but only after a significant delay. Interviews with the residents and their representatives confirmed that delays in incontinence care were a recurring issue, with reports of residents often being found soaked with urine and staff attributing the delays to other shifts. The electronic medical record and care plans confirmed the residents' dependence on staff for incontinence care and the required frequency of care, which was not met on the day of observation. The deficiency was directly observed and corroborated by staff and family interviews.